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Emergency and Disaster Preparedness and Response Planning: A Guide for Boards of Pharmacy

November 2006

Issued by:

National Association of Boards of Pharmacy 1600 Feehanville Drive

Mount Prospect, IL 60056

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Emergency and Disaster Preparedness and Response Planning: A Guide for Boards of Pharmacy

Table of Contents

Executive Summary ...................................................................................................................... 3 Introduction: Emergency and Disaster Preparedness and Response: Roles of Federal, State, and Local Governments..................................................................................................... 5 Recommendations for Preparing and Responding to an Emergency or Disaster .................. 9

I. Early Preparation for an Emergency or Disaster ................................................................ 9 II. Immediate Response to an Emergency or Disaster .......................................................... 10 III. Short-Term Response: The First 72 Hours Post-Disaster................................................. 12 IV. Long-Term Response: 72 hours to 30 Days (Possibly Longer) Post Disaster.................. 13

Appendix A: Model Emergency and Disaster Preparedness and Response Plan................ 14 I. Emergency Planning ......................................................................................................... 14 II. Maintaining Board of Pharmacy Operations .................................................................... 18 III. Communication................................................................................................................. 25 IV. Evacuation Planning ......................................................................................................... 26 V. Shelter-in-Place Planning ................................................................................................. 28 VI. Protecting Resources......................................................................................................... 30

Appendix B: Model Rules for Public Health Emergencies ..................................................... 34 Appendix C: Emergency and Disaster Resources Provided by NABP .................................. 41 References.................................................................................................................................... 42

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Executive Summary The Task Force on Emergency Preparedness, Response, and the US Drug Distribution System met on November 16-17, 2006. The appointment of this Task Force was in response to Resolution 102-4-06, Emergency Preparedness, Response, and the US Drug Distribution System, approved by the NABP membership at NABP’s 102nd Annual Meeting in San Francisco, CA. This resolution recommended that NABP continue its efforts to develop a response plan to natural and man-made disasters that affect the US drug distribution system, in collaboration with government agencies, national professional associations, and industry representatives. The Task Force was specifically charged with developing a “Model Emergency Disaster Preparedness and Response Plan” that would serve as a vital resource for the Boards. In order to complete this charge, the Task Force members were asked to examine the current and evolving role of the boards of pharmacy in emergency disaster preparedness and response, identify how NABP could assist the boards of pharmacy in their efforts to implement a disaster response plan, and recommend ways in which the boards of pharmacy and NABP can collaborate with government, industry, and other stakeholders in emergency disaster preparedness and response efforts. After significant discussion of the issues including, but not limited to, the roles of local, state, and federal governments in emergency preparedness and response, the recent roles of, and challenges faced by, the boards of pharmacy as a result of 2005 Hurricanes Katrina and Rita, and needed partnerships between the boards of pharmacy and the public and private sectors in coordinating emergency preparedness and response efforts, the Task Force conveyed a number of recommendations to the NABP Executive Committee. Additionally, as charged, the Task Force members produced this comprehensive model template, the “Emergency and Disaster Preparedness and Response Planning: A Guide for the Boards of Pharmacy.” The Guide contains, among other items, NABP’s “Recommendations for Preparing and Responding to an Emergency or Disaster,” a “Model Emergency and Disaster Preparedness Response Plan,” and “Model Rules for Public Health Emergencies,” as well as emergency and disaster resources provided to boards by NABP. NABP’s “Recommendations for Preparing and Responding to Emergency or Disaster” provide a timeline for the boards of pharmacy to employ in preparing and responding to an event. Its “Early Preparation for an Emergency or Disaster” section directs the boards of pharmacy to work proactively to create emergency and disaster preparedness and response plans, work with the state legislature to enact emergency dispensing and other related provisions, develop rules, and develop a contact list of public and private stakeholders, with whom the board of pharmacy may work in the case of a disaster. The “Immediate Response to an Emergency or Disaster” section provides a foundation for the board’s response in the event of an impending situation, outlining when the board should activate its emergency or disaster plans, make initial contact with various stakeholders crucial to response efforts, and release important information to licensees, the general public, the media, and others. The “Short-Term Response” section addresses the board’s response up to 72 hours post-event, directing the board to continue its immediate response

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activities, while basing further action upon up-to-date information received from, for example, state and federal agencies, or others. Finally, the “Long-Term Response” section addresses the continuing response activities, including, if necessary, efforts to restore board operations, sustain communications with important stakeholders, and provide continuous updates to licensees, the general public, the media, or others. The “Model Emergency and Disaster Preparedness and Response Plan” consists of six comprehensive sections that form a template to develop or supplement an existing emergency or disaster preparedness and response plan. This Model Plan has sections on Emergency Planning, Maintaining Board of Pharmacy Operations, Communications, Evacuation Planning, Shelter-in-Place Planning, and Protecting Business Resources. The “Model Rules for Public Health Emergencies,” which are intended to be incorporated into the Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy (Model Act), and which are outlined above, provide suggested statutory and/or regulatory language intended to enable pharmacists, pharmacies, and other licensees to assist in the management and containment of a public health emergency or similar crises. The provisions address emergency prescription drug orders, emergency refill dispensing, temporary recognition of non-resident licensure, and temporary or mobile pharmacy facilities. Finally, the Guide outlines emergency and disaster resources provided by NABP to assist boards in their efforts. Currently, NABP offers expedited licensure transfer and verification services to allow boards to swiftly register and recognize non-resident pharmacists and pharmacy technicians.

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Introduction

Emergency and Disaster Preparedness and Response: Roles of Federal, State, and Local Governments

To effectively prepare for and respond to an emergency or disaster, boards of pharmacy must have an understanding of the interplay between federal, state, and local governments in preparedness and response management. By understanding these processes at the various levels of government, boards of pharmacy are better enabled to develop robust emergency and disaster plans that are complementary to existing broader based efforts aimed at minimizing the impact of a disaster. This summary is not intended to provide a complete and comprehensive review of the intricate governmental layers of preparedness and response, thus boards of pharmacy are encouraged to contact their state emergency management agencies as well as consult the references included in this guidance (see Reference section). Federal Preparedness and Response1

National Incident Management System, National Response Plan, and the US Department of Homeland Security

The National Incident Management System (NIMS) provides a nationwide template enabling federal, state, local, and tribal governments and private sector and nongovernmental organizations to work together to effectively and efficiently prevent, prepare, respond to, and recover from domestic incidents of all causes, sizes, or complexities. The National Response Plan (NRP), utilizing NIMS, serves as the principal guide for managing domestic crises. The product of Homeland Security Presidential Directive (HSPD)-5, NRP provides a comprehensive approach to preventing, preparing for, responding to, and recovering from events with potential national or long-term implications, such as terrorist attacks, natural disasters, and public health emergencies requiring a coordinated federal response. Designed to allow maximum flexibility, the Plan can be partially or fully implemented, as appropriate, to meet the unique operational and information-sharing requirements of any emergency situation. The Plan outlines how the federal government will coordinate with various state, local, tribal, private-sector, and other nongovernmental entities. Together, the NRP and NIMS integrate a number of entities, public and private, federal and local, for an overall national framework for emergency preparedness and response. Established pursuant to the Homeland Security Act of 2002, the US Department of Homeland Security’s (DHS) purpose is to prevent terrorist attacks within the United States and reduce the vulnerability to, minimize damage from, and assist in recovery efforts as a result of domestic terrorism, natural disasters, and other emergencies. DHS is the lead federal department in crises and emergency management. The Federal Emergency Management Agency (FEMA), under the auspices of the DHS, is charged with preparing for all domestic hazards and managing the federal response and recovery efforts following any national incident. FEMA also initiates

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proactive mitigation activities, trains first responders, and manages the National Flood Insurance Program. Emergency Support Function Annexes

Emergency Support Function Annexes (ESFAs) are the primary means by which the federal government provides assistance to state, local, and tribal governments, or to federal departments and agencies conducting missions of primary federal responsibility, during actual or potential domestic incidents. Outlined in the NRP, ESFAs include specific emergency support resources (eg, transportation, firefighting, public health services) available for dispatch during incidents requiring a coordinated federal response. Currently, the NRP contains 15 ESFAs coordinated by a multitude of various federal agencies such as the US Department of Transportation, the Environmental Protection Agency, and Coast Guard. US Department of Health and Human Services

Specifically, ESFA # 8, primarily coordinated by the US Department of Health and Human Services (HHS), entails public health and medical services contingencies. When required, HHS would be responsible for providing supplemental assistance to state, local, and tribal governments by assessing the medical and behavioral health needs of victims as well as providing public health surveillance and the medical personnel, equipment, and supplies. HHS would provide these services utilizing its umbrella agencies, offices, and divisions, such as the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the US Public Health Service (PHS). For example, PHS, a division of HHS, is the federal nonmilitary, uniformed force of health care professionals who work in various agencies, including FDA, Indian Health Service (IHS), Federal Bureau of Prisons, Immigration and Customs Enforcement (ICE), Coast Guard, and CDC.2 The mission of PHS is to provide highly trained and mobile health professionals who carry out programs to promote the health of the nation, understand and prevent disease and injury, ensure safe and effective drugs and medical devices, deliver health services to federal beneficiaries, and furnish health expertise in time of war or other national or international emergencies. The PHS is led by the Surgeon General and consists of approximately 6,000 officers in the following professional categories: nursing, dentistry, pharmacy, dietetics, medical, veterinary, engineering, environmental health (including physical, occupational, speech, and audiology therapy), and other health services (including social work, optometry, statistics, and computer science). Strategic National Stockpile3

The Strategic National Stockpile (SNS), operated by CDC, is a national repository of antibiotics, chemical antidotes, antitoxins, life-support medications, IV administration devices, airway maintenance supplies, and medical/surgical items. The SNS is designed to supplement and re-supply state and local public health agencies in the event of a national emergency anywhere and at any time within the US or its territories. During a national emergency, state, local, and private stocks of medical supplies will be depleted quickly. While the SNS is not a first response tool, state and local first responders and health officials can use the SNS to bolster their responses to a national emergency.

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The SNS is organized for flexible response. The first line of support is the immediate-response 12-hour Push Packages. These are caches of pharmaceuticals, antidotes, and medical supplies for rapid delivery in the early hours of an event. These Push Packages are positioned in strategically located, secure warehouses and are ready for immediate deployment to a designated site within 12 hours of the federal decision to deploy SNS assets. If an incident requires additional pharmaceuticals and/or medical supplies, follow-up vendor-managed inventory (VMI) supplies are shipped to arrive within 24 to 36 hours. If the agent is well defined, VMI can be tailored to provide pharmaceuticals, supplies, and/or products specific to the suspected or confirmed agent(s). In this case, the VMI could serve as the first option for immediate response from the SNS Program. State/Local Preparedness and Response1

At the local level, first responders such as law enforcement, fire personnel, and emergency medical teams are often the first to arrive at an incident site. In some instances, a federal agency in the local area may act as a first responder and may advise or assist state or local officials in accordance with agency authorities and procedures. Mutual aid agreements provide mechanisms to mobilize and employ resources from neighboring jurisdictions to support the incident command. When state resources and capabilities are overwhelmed, governors may request federal assistance under a presidential disaster or emergency declaration. As outlined in the NRP, the governor is responsible for the safety and welfare of the people of that state or territory. The governor has the following responsibilities: (1) coordinates state resources to prevent, prepare for, respond to, and recover from incidents in situations such as terrorism, natural disasters, accidents, and other contingencies; (2) under certain emergency conditions, typically has police powers to make, amend, and rescind orders and regulations; (3) provides leadership in communicating to the public and in helping people, businesses, and organizations cope with the consequences of any declared emergency within state jurisdiction; (4) encourages participation in mutual aid and implements authorities for the state to enter into mutual aid agreements, with other states, tribes, and territories to facilitate resource-sharing; (5) serves as commander-in-chief of state military forces; and (6) requests federal assistance when state or tribal capabilities are insufficient or have been exhausted. A mayor or city or county manager, as a jurisdiction’s chief executive, is responsible for the public safety and welfare of the people of that jurisdiction. Similar to the governor, the mayor or city or county manager has the following responsibilities: (1) coordinates local resources to prevent, prepare for, respond to, and recover from incidents involving all hazards including terrorism, natural disasters and accidents, and other contingencies; (2) depending on state or local law, has extraordinary powers to suspend local laws and ordinances, such as to establish a curfew, direct evacuations, and, in coordination with the local health authority, to order a quarantine; (3) provides leadership in communicating to the public and in helping people, businesses, and organizations cope with the consequences of any domestic incident within the jurisdiction; (4) negotiates and enters into mutual aid agreements with other jurisdictions to

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facilitate resource-sharing; and (5) requests state and, if necessary, federal assistance through the governor of the state when the jurisdiction’s capabilities have been exceeded or exhausted.

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Recommendations for Preparing and Responding to an Emergency or Disaster4

Modeled and adapted from the Georgia Pharmacy Foundation’s An Action Plan for State Pharmacy Associations to Respond to Natural or Man-Made Disasters (March 1996), the “Recommendations for Preparing and Responding to Emergency or Disaster” section provides a timeline for the boards of pharmacy to employ in preparing and responding to an event

I. Early Preparation for an Emergency or Disaster In most cases, emergencies and disasters occur with little or no warning. In order to be best prepared, boards of pharmacy can start developing contingency plans well in advance. Specifically, boards of pharmacy should consider the following: 1. Creating an emergency and disaster preparedness and response plan specifically for

the board of pharmacy; 2. Working with the state legislature to enact emergency dispensing and other related

provisions; 3. Developing and maintaining a contact list of local/state government agencies and

national pharmacy organizations; 4. Developing and maintaining a contact list of local/regional pharmaceutical

manufacturers, wholesale drug distributors, and pharmacies that could donate and provide storage sites and transportation resources for critical drugs and supplies; and

5. Educate licensees on board efforts related to emergency or disaster planning.

1. Create an Emergency and Disaster Preparedness and Response Plan Using the NABP Model Emergency and Disaster Preparedness and Response Plan as a guide, boards of pharmacy can take perhaps the most important step in preparing for an emergency or disaster, ensuring that the board has an operational plan to remain functional to continue to fulfill its mission of protecting the public health. See Appendix A: “NABP Model Emergency and Disaster Preparedness and Response Plan.”

2. Work with the State Legislature to Enact Emergency Dispensing and Other Related Provisions If the state pharmacy practice act currently contains emergency dispensing provisions, the boards should review the provisions and revise if necessary. For guidance, boards of pharmacy should consider utilizing NABP’s “Model Rules for Public Health Emergencies,” found in Appendix B. In addition, boards should work with the legislature and appropriate agencies to ensure the state’s “emergency declaration” contains language appropriate to trigger the activation of emergency rules related to needed pharmacy services. Boards should also work within their states to ensure that pharmacists are designated as “first responders” in a disaster or emergency so they have access to needed prophylactic medications and vaccines.

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3. Develop and Maintain a Contact List of Local/State Government Agencies

and National Pharmacy Organizations Boards of Pharmacy should have contact information for local offices and agencies, including, but not limited to, the governor’s office, the department of public health, state emergency management agency, county health departments, and the state/local chapter of the American Red Cross, as well as national pharmacy organizations. Boards of pharmacy should also consider meeting with the local agencies to ensure that emergency or disaster plans of these agencies complement the board’s emergency or disaster plan. Boards should also be familiar with local law enforcement security plans in the event of an emergency or disaster.

4. Develop and Maintain a Contact list of Local/Regional Pharmaceutical

Manufacturers, Wholesale Drug Distributors, Pharmacies, Pharmacists and Technicians Local and regional pharmaceutical manufacturers, wholesale drug distributors, and pharmacies are in a unique position to help in an emergency or disaster by lending temporary storage and shipping facilities as well as providing critical drugs and supplies. Developing contacts, and in some cases memorandums of understanding, with these entities in advance of an emergency or disaster could dramatically improve the response time in getting supplies where they are needed in addition to maintaining the integrity of drugs and supplies. In some cases, transportation may also be challenged. Boards should also consider working with these entities to assist in transportation efforts. Boards may also consider developing a list of pharmacists and technicians who are willing to volunteer their services in the case of an emergency or disaster. In the alternative, a board may choose to simply access such a list if one is maintained by a national group. Such a list may contain volunteer credentials, such as CPR, first aid, or immunization certification.

5. Educate Licensees on Board Efforts Related to Emergency or Disaster

Planning Boards should keep licensees up-to-date on emergency and disaster planning

efforts via Web sites, newsletters, etc. Boards may also consider developing or distributing a template for state-licensed pharmacies to use in developing a disaster or emergency plan.

II. Immediate Response to an Emergency or Disaster At the point an emergency or disaster is declared, there may be limited time to respond. Boards of pharmacy should take the following steps prior to an emergency or disaster: 1. Activate the Board emergency or disaster response plan, place board of pharmacy

members and staff on “standby;”

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2. Initiate contact with local/state emergency management agencies, pharmaceutical manufacturers, wholesale drug distributors, pharmacies, and other entities if necessary;

3. Initiate contact with NABP regarding the potential need for emergency or disaster resource assistance; and

4. Alert licensees, national and local pharmacy associations, and the public.

1. Activate Emergency or Disaster Response Plan, Place Board of Pharmacy Members and Staff on “Standby” In the event of an emergency or disaster, the board of pharmacy executive director/secretary or chief administrator, as the primary crisis manager, should activate the board’s emergency or disaster plan. During normal business hours, the primary crisis manager may consider conducting a brief meeting to provide information to staff regarding the status of the disaster, including such information as anticipated staffing needs or mandatory evacuation of the board facility. If not during normal business hours, depending on the specific emergency or disaster, the primary crisis manager may call the emergency planning team (as described in Appendix A) to assist in contacting staff at home with specific updates and instruction.

Boards of pharmacy should also consider alternative forms of communication with board members, staff, and the public in case normal modes of communication are compromised.

2. Initiate Contact with Local/State Emergency Management Agencies,

Pharmaceutical Manufacturers, Wholesale Distributors, Pharmacies, and Other Entities As an emergency or disaster unfolds, the board of pharmacy will most likely not be working unilaterally but, instead, will be working in concert with other entities, particularly local/state government agencies. Boards of pharmacy should initiate contact with the appropriate entities to begin to coordinate efforts and optimize response. Working with local/state government agencies and, in some cases, with federal agencies, boards can serve as an important link to private entities, such as pharmaceutical manufacturers, wholesale drug distributors, and others in the pharmaceutical industry that may be of assistance. Boards should also contact other entities, such as Internet and telecommunication service providers, to discuss the maintenance of communication lines during and in the immediate aftermath of the emergency or disaster.

3. Initiate Contact with NABP Regarding the Potential Need for Emergency or

Disaster Resource Assistance. Boards of pharmacy should contact NABP regarding the potential need for emergency or disaster resource assistance. NABP provides expedited licensure verification and transfer services to ensure adequate personnel are available to provide needed pharmacy care services in affected areas. Other services provided by NABP are described in Appendix C.

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4. Alert Licensees, National and Local Pharmacy Associations, and the Public

Boards should make particular efforts to alert all necessary parties of the impending emergency or disaster. The board of pharmacy should consider using its Website as a tool in communicating crucial information, not only to the public and licensees, but also to board members and staff, if necessary. Boards may consider posting on their Web sites emergency-related regulations, such as emergency dispensing provisions, or emergency-related notices, such as board office relocation and temporary contact information. Also, boards may consider using calling trees, blast faxes, and email list servs to disseminate information.

III. Short-Term Response: The First 72 Hours Post-Disaster The period immediately following an emergency or disaster is perhaps the most critical in that there may be limited or no state or federal aid available (typical time frame for a state or federal disaster to be declared is 72 hours) and local resources may be quickly overwhelmed. Communication systems may be challenged and public utilities, like electricity and water, may be unavailable. Also, information concerning an accurate assessment of the emergency or disaster may be limited. During this critical time, boards of pharmacy should: 1. Continue to employ the board’s emergency or disaster response plan; 2. Initiate contacts with local/state government agencies to determine the public’s

medical and health needs; 3. Maintain communication with wholesale distributors and pharmaceutical

manufacturers to ensure that adequate supplies of drugs and supplies are available and accessible;

4. Maintain use of NABP emergency and disaster resource assistance; and 5. Provide frequent information and updates, if possible, through various channels to

licensees, the public, and other identified entities.

1. Continue to Employ the Board’s Emergency or Disaster Response Plan During this phase of the disaster, the board of pharmacy should be assessing internal needs in order to maintain identified critical operations. This may include increasing staffing and equipment or determining whether or not the board will be operating at an alternate location. Depending on the emergency or disaster, the board may decide to cease all operations.

2. Initiate Contacts with Local/State Government Agencies to Determine Public

Health Needs The board of pharmacy serves as an important resource to local/state emergency management agencies as the needs of the public are assessed. The board of pharmacy is equipped to serve as one of the primary coordinating agencies for the receipt and distribution of supplies through its contacts with the private industry. Additionally, through its relationship with local and state professional associations, the board of pharmacy may also be able to help with the coordination and disbursement of volunteers.

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3. Maintain Communication with Pharmaceutical Manufacturers, Wholesale Drug Distributors, and Pharmacies to Ensure Adequate Supplies of Drugs and Medical Equipment are Available and Accessible Depending on information available to the board of pharmacy regarding initial assessments of the emergency or disaster, the board may be able to relay specific drug and supply needs to the industry, including but not limited to, identifying temporary or mobile facilities.

4. Maintain Use of NABP Emergency and Disaster Resource Assistance Continued use of NABP’s expedited licensure verification and transfer services

will ensure that adequate numbers of pharmacists and pharmacy technicians can be put into place to serve needed areas.

5. Provide Frequent Information and Updates through Various Channels to

Licensees, the Public, and Other Identified Entities The board serves as an important source of information and should utilize appropriate means of communication to provide updates and other specifics. For example, the board may want to post its temporary license applications on its Web site or provide consumers with important information on obtaining necessary medications.

IV. Long-Term Response: 72 hours to 30 Days (Possibly Longer) Post Disaster The long-term recovery period following an emergency or disaster varies and, depending on the disaster, may be as short as 30 days or as long as 12 months. Although the board’s focus will shift from acute to more long-term concerns, the board should continue the efforts that began immediately following the disaster. These efforts include working to restore and maintain critical board operations, sustaining communications with important stakeholders, such as local/state emergency response agencies and pharmaceutical industry contacts; and providing updates to the public and licensees. The board may also need to assist licensees in their efforts to restore operations by providing guidance on associated regulatory aspects pertaining to the emergency or disaster.

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Appendix A: Model Emergency and Disaster Preparedness and Response Plan5

The NABP Model Emergency and Disaster Preparedness and Response Plan is intended to assist boards of pharmacy in developing a tailored and detailed emergency preparedness and response document. Modeled and adapted from the Ready Business Mentoring Guide: Working with Small Businesses to Prepare for Emergencies, issued by the US Department of Homeland Security, this Plan consists of six comprehensive sections and provides a template to develop or supplement existing emergency and disaster plans. With local/state government agencies serving as primary emergency responders, boards of pharmacy are strongly encouraged to proactively work with their local/state agency counterparts to learn about existing emergency preparedness and response plans and local/state specific contingencies into their own plans. In addition, by collaborating with local/state emergency response agencies, these entities can become aware of the resources and capabilities of the board in an emergency or disaster situation.

I. Emergency Planning

A. Emergency Planning Team A successful emergency or disaster preparedness and response plan is dependent upon the board’s continued commitment to encourage and authorize an emergency planning team to create a plan. First the board should determine which staff will be responsible for the development of the plan. The identified staff should be knowledgeable about most facets of the organization’s operations and facilities. The board may consider involving other employees from every level of the board so the plan can appropriately take into account all divisions of the board.

Emergency Planning Team The following board and staff members will participate in emergency planning and crisis management: (include name, title, contact information) 1. _______________________________________________________________________ 2. _______________________________________________________________________ 3. _______________________________________________________________________ 4. _______________________________________________________________________ 5. _______________________________________________________________________

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B. Emergency Contact Information The board should also have the emergency contact information, including cell phone numbers, for all staff and board members, and insurance company contact information (if applicable and whether or not it is state or privately issued insurance).

Emergency Contact Information Staff Name Cell No. Work No. Home No. e-mail ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Board Members Name Cell No. Work No. Home No. e-mail ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Insurance Provider ____________________________________________________________ Street Address________________________________________________________________ City_____________________________ State________________ Zip Code______________ Phone __________________ Fax________________ E-Mail ___________________________ Contact Name______________________ Policy Number ______________________________

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C. Risk Assessment In developing a robust emergency or disaster preparedness and response plan, the board and its emergency planning team should evaluate the probability or risk that specific disasters or emergencies may impact the board. Threats could include both natural and man-made, ranging from floods and power outages to technological threats and terrorism. By knowing what types of risks your board is more likely to encounter, the emergency planning team will be better equipped to determine the needs of the board in the event of a disaster or emergency as well as focus efforts on preparation activities on situations that are likely to affect the board.

The board may consider completing the following Risk Assessment Survey. Rank the likelihood that any of the following scenarios will occur, the impact it will have on the board, and the amount of warning time available before it occurs.

Risk Assessment Survey Disaster/Emergency Likelihood of

Occurrence (1 to 5) Impact on Board (minimal, moderate, severe)

Warning Time (Days, Hours, Min)

Natural Flood Hurricane Thunderstorm/ Lightning

Tornado Winter Storm/Extreme Cold

Extreme Heat Earthquake Volcano Landslide Tsunami Fire Wildfire Pandemic Illness Technological Hazardous Material Nuclear Power Plant Power Outage Cyber Security Nuclear Blast Radiological Dispersion Device

Disasters/ Emergencies Specific to the Board

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1. 2. 3.

D. Emergency Supplies The emergency planning team should prepare a list of supplies that the board should store on location. Items to include may be essentials such as water and food, and a basic first-aid kit. See below for a list of recommended emergency supplies. The emergency planning team should also determine an appropriate place to store these items so as to minimize any potential damage in the event of a disaster, while at the same time ensuring easy accessibility. The emergency planning team may also consider obtaining signage that would allow the office to communicate to emergency personnel in case of quarantine. The board may also encourage employees to maintain their own personal emergency supply kits, including items such as medications, a mini-flashlight, an emergency whistle, water, snacks, etc.

Essential documents, including this Emergency and Disaster Preparedness and Response Plan, building plans, insurance documents, contracts, employee contact information, and electronic back up media should be sealed in a waterproof/fireproof container, with a duplicate set of items stored offsite.

The following are recommended emergency supplies. The board should include additional items as it deems appropriate. Additionally, each staff member should be encouraged to prepare a personal emergency supply kit, consisting of a three-day supply of necessities, including medications. Emergency Supplies – Minimum Three-Day Supply Water (one gallon of water per person per day for drinking and sanitation) Food (non-perishable) Battery-operated radio and extra batteries NOAA weather radio and extra batteries Flashlights and extra batteries First-aid kit Whistle (to signal for help) Dust or filter masks (minimum N-95 mask) Moist towelettes (for sanitation) Tool Kit, including wrench or pliers to turn off utilities Can opener for food Plastic sheeting and duct tape to “seal the room” Garbage bags and plastic ties for personal sanitation Satellite phone/two-way radios Safety glasses Sleeping bags/pillows Gore-Tex or waterproof rain suit Rubber boots

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Other: Other: Other:

E. Immunizations The following is a list of immunizations recommended for all board of pharmacy members and staff to ensure appropriate preparation for an emergency or disaster: Immunization Frequency 1._____________________________________________________________________________ 2._____________________________________________________________________________ 3._____________________________________________________________________________ 4._____________________________________________________________________________ 5._____________________________________________________________________________ 6._____________________________________________________________________________ 7._____________________________________________________________________________8._____________________________________________________________________________ F. Staff Education and Training The board should conduct regularly scheduled staff education and training seminars to provide information, identify needs, and develop preparedness skills, including, on a regular basis, emergency preparedness and safety information in board communications, e-mails, and staff meetings to complement formalized training efforts. The identification and consideration of staff with disabilities or special communication needs is key. The board may consider drills where staff actually performs their designated emergency or disaster functions. The board may consider maintaining staff education and training records.

The board may also direct staff to walk the evacuation route to a designated area where procedures for accounting for all personnel are tested. Processes and procedures should be re-evaluated and revised based on information gathered from practice drills. If boards share office space with another entity, coordinating emergency plans should be considered.

II. Maintaining Board of Pharmacy Operations

A. Primary/Secondary Crisis Managers It is important for boards to designate a primary and a secondary crisis manager. In most cases, the board’s executive director or secretary serves as the primary crisis manager and the assistant executive director or chief compliance officer/investigator serves as the secondary crisis manager. The role of the primary crisis manager is to oversee and execute the emergency or disaster response plan and serve as the primary spokesperson for the board. In the event that the primary crisis manager is unavailable, the secondary crisis manager will assume that role.

Primary Crisis Manager

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Name/Title ____________________________________________________________________ Phone ________________________________________________________________________ Alternative Phone _______________________________________________________________ E-Mail________________________________________________________________________ Secondary Crisis Manager Name/Title _____________________________________________________________________ Phone_________________________________________________________________________ Alternative Phone________________________________________________________________ E-Mail_________________________________________________________________________ B. Remote Electronic Access to Data Should the board office become inaccessible, it will be important for board staff and board members to have remote electronic access to certain data and operating systems. List each staff and board member, the data and operating systems to which they will have access, and the mechanism by which they will have access. Staff name _________________________________________________________________ Data and operating systems to be accessed _______________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Mechanism to access _________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Staff name _________________________________________________________________ Data and operating systems to be accessed _______________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Mechanism to access _________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Staff name _________________________________________________________________ Data and operating systems to be accessed _______________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Mechanism to access _________________________________________________________

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___________________________________________________________________________ ___________________________________________________________________________ Board member name__________________________________________________________ Data and operating systems to be accessed _______________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Mechanism to access _________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Board member name__________________________________________________________ Data and operating systems to be accessed _______________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Mechanism to access _________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Board member name__________________________________________________________ Data and operating systems to be accessed _______________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Mechanism to access _________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ C. Alternate Location Site The board may want to designate an alternate location from which to continue board operations if the board office becomes inaccessible. For example, the board may operate from a residential location or perhaps a location provided by the state.

Alternate Location Site Address________________________________________________________________________ City, State______________________________________________________________________ Phone _________________________________________________________________________

D. Critical Functions

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Before an emergency or disaster occurs, the board should determine the most critical and vital functions needed to maintain board operations. In determining these functions, boards may consider identifying the various resources and procedures that are absolutely essential to each function. Boards should also assess how its functions, both internally and externally, affects demands for staff, materials, procedures and equipment. For completion of this section, list the board’s critical functions, the staff charged with maintaining each function in the event of an emergency or disaster, and the procedures for maintaining each function and recovering from the emergency or disaster. It is also important to distinguish which functions are critical depending on the nature of the emergency or disaster.

Our Critical Functions The following is a prioritized list of critical functions, staff, and procedures needed to maintain and recover from a disaster.

Function #1 _______________________________________________________________ Staff in Charge ______________________________________________________________ Action Plan _________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Function #2 _______________________________________________________________ Staff in Charge ______________________________________________________________ Action Plan _________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Function #3 _______________________________________________________________ Staff in Charge ______________________________________________________________ Action Plan _________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Function #4 _______________________________________________________________ Staff in Charge ______________________________________________________________ Action Plan _________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

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___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Function #5 _______________________________________________________________ Staff in Charge ______________________________________________________________ Action Plan _________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Function #6 _______________________________________________________________ Staff in Charge ______________________________________________________________ Action Plan _________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

E. Suppliers and Contractors Another element in emergency preparedness involves identifying the supplier, contractors, resources and other entities with which the board interacts on a daily basis. In many cases, developing relationships with more than one company can help maintain critical board operations in case the board’s primary contractor cannot service the board’s needs.

Necessary Materials/Services ____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Primary Supplier Company Name_________________________________________________________________ Street Address__________________________________________________________________

City________________________________ State _______________ Zip Code______________

Phone ______________Fax________________ E-Mail __________________________________

Contact Name_____________________________ Account Number ________________________

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Secondary Supplier Company Name_________________________________________________________________ Street Address__________________________________________________________________

City______________________________ State________________ Zip Code______________

Phone ______________Fax________________ E-Mail:__________________________________

Contact Name_____________________________ Account Number:________________________

Materials/Services Provided ________________________________________________________ Necessary Materials/Services ____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Primary Supplier Company Name_________________________________________________________________ Street Address__________________________________________________________________


Phone ______________Fax________________ E-Mail:__________________________________


Secondary Supplier Company Name_________________________________________________________________ Street Address__________________________________________________________________


Phone ______________Fax________________ E-Mail:__________________________________


F. Record Preservation The preservation of vital records is crucial for timely and prompt restoration of board operations in the event of an emergency or disaster. Identifying the minimum information needed to perform critical board operations should guide the board on the specific records

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and the equipment that will be needed to access and use the information found in such records. The board should copy (electronic and/or hard document) all critical records and data on a regular basis and keep copies offsite. There are off-site data storage businesses that can assist the board in copying and storing all critical records and data. In addition, backing up all computer systems on a regular basis and labeling vital records for easy identification and access can be particularly helpful. If a disaster is imminent, the board may consider using heavy-duty plastic bags to store, protect, and transport smaller electronic equipment and paper files. The board should also identify critical equipment and documents that should be removed or relocated to another designated location. Record Preservation Vital board records and data that must be copied and stored off site are: 1. This Emergency and Disaster Preparedness and Response Plan 2. Site maps 3. Insurance policies 4. Accounting records, including payroll data 5. ___________________________________________________________________________ 6. ___________________________________________________________________________ 7. ___________________________________________________________________________ 8. ___________________________________________________________________________ 9. ___________________________________________________________________________ 10. ___________________________________________________________________________ The on-site location(s) of the records listed above are as follows: 1. This Plan – _________________________________________________________________ 2. Site maps – _________________________________________________________________ 3. Insurance policies – ___________________________________________________________ 4. Accounting records – _________________________________________________________ 5. ___________________________________________________________________________ 6. ___________________________________________________________________________ 7. ___________________________________________________________________________ 8. ___________________________________________________________________________ 9. ___________________________________________________________________________ 10. ___________________________________________________________________________ The off-site location(s) of the records listed above are as follows: 1. This Plan – __________________________________________________________________ 2. Site maps – _________________________________________________________________ 3. Insurance policies – ___________________________________________________________ 4. Accounting records – __________________________________________________________ 5. ___________________________________________________________________________ 6. ___________________________________________________________________________ 7. ___________________________________________________________________________

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8. ___________________________________________________________________________ 9. ___________________________________________________________________________ 10. ___________________________________________________________________________

The person responsible for copying board records and ensuring the appropriate on- and off-site storage is _______________________________________________________________(Staff Person/Title).

III. Communication

A. Crisis Communication Plan The board’s ability to effectively communicate with staff, licensees, local authorities, and the public during an emergency or disaster is critical. As the board develops a crisis communication plan, it should contemplate how it would communicate with both internal (ie, staff) and external (ie, licensees) entities considering normal modes of communication may be inoperable (ie, lack of electricity, telephone lines down, etc). In developing a crisis communication plan, the board should contemplate all possibilities, from short-term disruption to full communications failure. The board should also inquire with its various communication vendors about emergency preparedness and response capabilities.

The board may consider developing a telephone call tree, password-protected pages on the board’s Web site, an e-mail listserv alert, or a call-in voice recording to communicate with staff, members and licensees during an emergency or disaster. Maintaining an updated staff, member, and licensee roster with multiple contact phone numbers, fax numbers, and e-mail addresses is recommended. Boards should also consider maintaining a Web page with current licensee information to assist in necessary license verification efforts in the case of an emergency or disaster. The board may also consider contacting the media with updates or using prerecorded public service announcements to communicate with the public. Maintaining an up-to-date media contact list containing phone and fax numbers and e-mail addresses is recommended.

Crisis Communication Plan During an emergency or disaster, the board will communicate with STAFF by: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ During an emergency or disaster, the board will communicate with BOARD MEMBERS by: ____________________________________________________________________________________________________________________________________________________________

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____________________________________________________________________________________________________________________________________________________________ During an emergency or disaster, the board will communicate with LICENSEES (including pharmacists, pharmacies, students, technicians, etc.) by: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ During an emergency or disaster, the board will communicate with other STATE AGENCIES by: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ During an emergency or disaster, the board will communicate with the PUBLIC by: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IV. Evacuation Planning

A. Evacuation Plan One of the most critical decisions during an emergency or disaster can be choosing whether to remain on site or to evacuate the premises. It is strongly recommended that boards follow the warnings and direction from local, state, and federal officials. To facilitate this effort, an Evacuation Plan should be developed by the board. Overall, the Plan should, at a minimum, describe a mechanism for identifying all persons present in the board office, describe the disaster warning system, identify the evacuation route, designate an assembly site, and identify staff responsible for ensuring all persons present in the board office are accounted for and for shutting down critical operations and securing the office or building. As mentioned above, the Plan should include a mechanism for identifying all persons present in the board office, including staff and visitors, so that all can be accounted for in case of an evacuation. An office visitor sign-in sheet and employee punch clock records can be used for this purpose. Boards should also consider the fact there may be staff or visitors with disabilities who may require assistance in evacuating the building. The description of the warning system should include the audio and/or visual signals to be used to warn of a disaster or emergency, building site maps with critical utility locations and clearly-marked emergency routes, with entry and exit points on the maps and throughout the building. Evacuation routes should be clearly posted and the board

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may consider installing emergency lighting or the use of flash lights in case there is loss of electricity. In identifying an assembly site, boards should choose at least two locations; a primary and a secondary location in the case evacuees must move farther away from the board office. The Plan should identify an assembly site manager who will be responsible for the assembly site during a disaster or emergency, and who will account for staff and visitors to determine any missing persons. The Plan should also identify a staff person responsible for shutting down critical operations and securing the board office or building. In addition, the Plan should identify the person who will determine when it is safe to halt the Evacuation Plan and issue an “all clear.” When the Evacuation Plan is finalized, staff should be trained and boards should consider practicing the evacuation procedures. If the board office is located in a high rise building or shares building space with other entities, the board should attempt to coordinate and practice with those entities to avoid confusion and gridlock. Boards should encourage staff to inform fellow staff if they cannot get to or must depart from the assembly site. Evacuation Plan Description of Disaster Warning System: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Disaster Warning System will be tested (frequency): ____________________________________________________________________________________________________________________________________________________________ Assembly Site Manager and Alternate: ____________________________________________________________________________________________________________________________________________________________ Primary assembly site: ____________________________________________________________________________________________________________________________________________________________ Secondary assembly site: ____________________________________________________________________________________________________________________________________________________________ Staff responsible for shutting down critical operations and securing board office: ____________________________________________________________________________________________________________________________________________________________

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Staff responsible for issuing “All Clear”: ____________________________________________________________________________________________________________________________________________________________

V. Shelter-in-Place Planning

A. Shelter-in-Place Plan There may be situations when it is best for persons present in the board office to take shelter immediately; for instance, during a tornado, chemical incident, or other incident where concerns are for the survival of board staff and visitors. If the board is advised by local authorities to take shelter, all persons should do so immediately. In reality, staff can not be forced to take shelter, but staff should be informed in advance of policies and procedures on sheltering to maximize cooperation in the event it is necessary. To facilitate this effort, a Shelter-in-Place Plan should be developed by the board. Overall, the Plan should, at a minimum, describe a mechanism for identifying all persons present in the board office, describe the disaster warning system, identify the shelter, and identify staff responsible for ensuring all persons present in the board office are accounted for and for shutting down critical operations and securing the office or building. As mentioned above, the Plan should include a mechanism for identifying all persons present in the board office, including staff and visitors, so that all can be accounted for. An office visitor sign-in sheet and employee punch clock records can be used for this purpose. Boards should also consider the fact that there may be staff or visitors with disabilities who may require assistance in taking shelter. As with the Evacuation Plan, the Shelter-in-Place Plan should include a description of the warning system, including the audio and/or visual signals to be used to warn of a disaster or emergency, building site maps with critical utility locations and clearly-marked emergency routes, with entry and exit points on the maps and throughout the building. The route to the shelter should be clearly posted and the board may consider installing emergency lighting or the use of flash lights in case there is loss of electricity. Identifying the shelter location, will depend on the specific circumstances. For example, in the case of a tornado, storm cellars or basements provide the best protection. If underground shelter is not available, an interior room or hallway on the lowest floor is best. Staff should be instructed to stay away from windows, doors, exterior walls, and corners. Staff should be advised to gather in the center of the room. In the event of air contamination as a result of an agent released from a chemical plant or a bioterrorism attack, the board may be instructed by local authorities to take shelter and “seal the room” in an inside room on a higher floor. By sealing the room, a temporary protective measure is created forming a barrier between the inside of the board office and the air contaminated outside. To “seal the room” effectively, the board should:

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1. Close the board office and direct everyone inside, preferably to an interior room with the fewest windows;

2. Lock all doors, close all windows, air vents, and fire place dampers; 3. Turn off all fans, air conditioning, and forced air heating systems; 4. Locate emergency supplies (unless contaminated); 5. Seal all windows, doors and air vents with plastic sheeting and duct tape. The board

may consider measuring, cutting and labeling the sheeting in advance to save time; 6. Stay tuned via radio, television, and/or Internet for official news and instructions as

they become available. The Plan should identify a shelter manager who will be responsible for the shelter during a disaster or emergency, and who will account for staff and visitors to determine any missing persons. The Plan should also identify a staff person responsible for shutting down critical operations and securing the board office or building. In addition, the Plan should identify the person who will determine when it is safe to halt the Shelter-in-Place Plan and issue an “all clear.” When the Shelter-in-Place Plan is finalized, as with the Evacuation Plan, staff should be trained and boards should consider practicing sheltering procedures. If the board office is located in a high rise building or shares building space with other entities, the board should attempt to coordinate and practice with those entities to avoid confusion and gridlock. Boards should encourage staff to inform fellow staff if they cannot get to or must depart from the shelter.

Shelter-in-Place Plan Description of Disaster Warning System: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Disaster Warning System will be tested (frequency): ____________________________________________________________________________________________________________________________________________________________ Shelter Manager and Alternate: ____________________________________________________________________________________________________________________________________________________________ Storm Shelter Location: ____________________________________________________________________________________________________________________________________________________________ “Seal the Room” Shelter Location: ____________________________________________________________________________________________________________________________________________________________

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Staff responsible for shutting down critical operations and securing board office: ____________________________________________________________________________________________________________________________________________________________ Staff responsible for issuing “All Clear”: ____________________________________________________________________________________________________________________________________________________________

VI. Protecting Resources

A. Cyber Security and Computer Inventory For most organizations, computers are crucial to most operations. It is vital, therefore, that organizations address cyber security. Every computer is vulnerable to cyber-security threats necessitating that all organizations dependent on computers for crucial functions take the appropriate measures to guard against hacking and viruses.

Boards should consider such precautions as: Regularly using up-to-date anti-virus software Discouraging staff from opening e-mails from unknown or unwanted sources Using hard-to-guess passwords Installing firewalls Electronically backing up data and storing it off-site Regularly downloading security update patches Assessing computer operation security on a regular basis Training personnel on policies and procedures in the event the board’s computer

system becomes infected

In the event that computer hardware is damaged or lost, boards should maintain an accurate inventory of all computers and hardware, including the serial and model numbers, date purchased, and cost. Boards should also include the company that provides repair and support for computer hardware.

Cyber Security The board will do the following to protect computer hardware: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ The board will do the following to protect computer software: ____________________________________________________________________________________________________________________________________________________________

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____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ In the event the board’s computers are destroyed, the board will: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

B. Supporting Board Staff Health and Well Being Encouraging staff to prepare for emergencies may help individuals and their families minimize the impact of the emergency or disaster on their lives. Staff will be able to re-establish routines faster and the board, as a whole, will be able to recover more quickly. Boards should keep in mind that staff may have special recovery needs and boards should be prepared to support employee health after a disaster.

In assisting the staff, the board should: 1. Encourage adequate food, rest, and recreation; 2. Provide for time at home to tend to family needs; 3. Encourage an open door policy that facilitates care when needed; 4. Create an atmosphere where staff can talk openly about their fears and hopes; sharing

with others can speed personal recovery; 5. Reassure families will be supported; worries about family well-being can consume

staff that has experienced a disaster; 6. Re-establish routines, when possible; workplace routines facilitate recovery by

providing an opportunity to be active and to restore social contact; 7. Offer professional counselors to help staff address their fears and anxieties; 8. Once the need to listen for emergency instructions has passed, limit television, radio

and other external stresses. C. Securing the Board Facilities The board can also take preparatory steps to protect and secure its facilities in the event of an emergency or disaster. For example: 1. Install fire extinguishers and smoke detectors in appropriate places and ensure that

staff members are instructed on appropriate use;

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2. Plan to provide building and site maps with critical utility locations and clearly-marked emergency routes to fire fighters or other first responders in the event of a disaster;

3. Consider whether or not the board could benefit from automatic fire sprinklers, alarm systems, closed circuit TV, access control, security guards or other security systems;

4. Secure ingress and egress. Consider all the ways in which people, products, supplies, and other things get into and leave your building or facility;

5. Plan for mail safety. The nation’s battle against terrorism takes place on many fronts, including the mailrooms of U.S. companies. A properly informed and well-trained workforce can overcome such threats; a. Teach employees to be able to quickly identify suspect packages and letters.

Warning signs include: i. Misspelled words

ii. No return address iii. Excessive use of tape iv. Strange discoloration or odor

b. The United States Postal Service (www.usps.com) suggests that if a suspect letter or package is identified:

i. Do not open, smell, touch or taste ii. Immediately isolate suspect packages and letters

iii. Move out of the area and do not let others in iv. Quickly wash with soap and water and remove contaminated clothing v. Contact local law enforcement authorities

6. Post emergency numbers for easy reference; 7. Identify and comply with all local, state, and federal codes and other safety

regulations that apply to your business; and 8. Talk to your insurance provider about what impact any of these steps may have on

your coverage.

D. Assessing Facility Air Protection In some emergencies, microscopic particles may be released into the air. A building can provide a barrier between contaminated air outside and people inside, but there are ways to improve building air protection. Depending on the size of the building and the design and layout of the heating, ventilating, and air conditioning (HVAC) system, there may be simple steps building owners and managers can take to help protect people from some airborne threats.

Boards should: 1. Know the HVAC system. Building owners, managers and employers should take a

close look at the site’s system and be sure it is working properly and is well-maintained, and ensure that any security measures do not adversely impact air quality or fire safety;

2. Develop and practice shut-down procedures for the HVAC system; 3. Secure outdoor air intakes. HVAC systems can be an entry point and means of

distributing biological, chemical and radiological threats:

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a. Limit access to air intake locations to protect the people inside a building from airborne threats. Air intakes at or below ground level are most vulnerable because anyone can gain easy access;

b. Consider relocating or extending an exposed air intake, but do not permanently seal it;

4. Determine if you can feasibly upgrade the building’s filtration system: a. Increasing filter efficiency is one of the few things that can be done in advance to

consistently protect people inside a building from biological and some other airborne threats;

b. Carefully consider the highest filtration efficiency that will work with a building’s HVAC system;

5. Use HEPA (High Efficiency Particulate Arrester) filter fans. These individual units have highly efficient filters that can capture very tiny particles, including many biological agents. While these filters are excellent at filtering dander, dust, molds, smoke, many biological agents, and other contaminants, they will not stop chemical contaminants.

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Appendix B: Model Rules for Public Health Emergencies

National Association of Boards of Pharmacy Model State Pharmacy Act

Article II …

Section 201. Designation The responsibility for enforcement of the provisions of this Act is hereby vested in the Board of Pharmacy. The Board shall have all of the duties, powers, and authority specifically granted by or necessary for the enforcement of this Act, as well as such other duties, powers, and authority as it may be granted from time to time by applicable law. In the event of a declared State of Emergency, the Board may waive the requirements of this Act in order to protect the public health, safety, or welfare of its citizens and to facilitate the provision of Drugs, Devices, and Pharmacist Care services to the public. …

Article III …

Comments

Section 201. Comment In states where centralized prescription filling or centralized prescription processing are not permitted, states may consider allowing the performance of such activities in a declared State of Emergency. …

Section 303. Comment See NABP’s Model Rules for Public Health Emergencies for language that addresses the temporary recognition of non-resident pharmacist licensure in the case of a declared State of Emergency issued due to a Public Health Emergency.

Model Rules for the Practice of Pharmacy …

Section 2. Personnel.

A. Duties and Responsibilities of the Pharmacist-in-Charge

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…

(2) The Pharmacist-in-Charge has the following responsibilities: …

(vii) a procedure for the operation of the Pharmacy, to the extent that the Pharmacy can be safely and effectively operated and the Drugs contained therein can be safely stored and Dispensed, in the event of a fire, flood, pandemic or other natural or man-made disaster or emergency; and

(vii) policies and procedures for reporting to the Board the occurrence of any fire, flood, or other natural or man-made disaster or emergency within 10 days of such occurrence.

…

Section 2A(2)(n) Comment States should recognize that hospitals, in order to prepare for a disaster or emergency, may be stocking emergency supplies of medications in areas outside the licensed Pharmacy. Hospitals should be encouraged to expand the space allotted to the licensed Pharmacy area to accommodate the need to store emergency supplies.

Model Rules for Public Health Emergencies

Section 1. Purpose and Scope By the provision of these rules by the Board, the primary purpose of the section is to enable Pharmacists and Pharmacies to assist in the management and containment of a Public Health Emergency or similar crisis within the confines of a regulatory framework that serves to protect the welfare and health of the public.

Section 2. Definitions. (a) “Declared Disaster Areas” are areas designated by the state or federal authorities

as those that have been adversely affected by a natural or man-made disaster and require extraordinary measures to provide adequate, safe and effective health care for the affected population.

(b) “Emergency Prescription Drug Order” means a standing Prescription Drug Order issued by the State Health Officer for Pharmacists to Dispense designated Prescription Drugs during a Public Health Emergency requiring mass Dispensing to expeditiously treat or provide prophylaxis to large numbers of Patients.

(c) “Mobile Pharmacy” means a Pharmacy that is self propelled or movable by another vehicle that is self propelled.

(d) “Public Health Emergency” means an imminent threat or occurrence of an illness or health condition caused by terrorism, bioterrorism, epidemic or pandemic disease, novel and highly fatal infectious agent or biological toxin, or natural or man-made disaster, that poses a substantial risk of a significant number of human

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fatalities or incidents of permanent or long-term disability that is beyond the capacity of local government or nongovernmental organizations to resolve.

(e) “State of Emergency” means a governmental declaration, usually issued as a result of a Public Health Emergency, that may suspend certain normal functions of government, alert citizens to alter their normal behaviors, and/or direct government agencies to implement emergency preparedness plans.

(f) “Temporary Pharmacy Facility” means a facility established as a result of a Public Health Emergency or State of Emergency to temporarily provide Pharmacy services within or adjacent to Declared Disaster Areas.

Section 3. Emergency Prescription Drug Order

(A) For the duration of a State of Emergency issued due to a Public Health Emergency, a Pharmacist may Dispense a Prescription Drug pursuant to an Emergency Prescription Drug Order if the Pharmacist:

(1) performs, to the extent possible, a Prospective Drug Regimen Review and Patient Counseling in accordance with these rules;

(2) reduces the information to a form that may be maintained for the time required by law or rule, indicates it is an “Emergency Prescription Drug Order,” and files and maintains the record as required by state and federal law.

Section 4. Public Health Emergency Refill Dispensing

(A) For the duration of the State of Emergency issued due to a Public Health Emergency in the affected state and in other states engaged in disaster assistance pursuant to a governmental declaration or rule of the Board, a Pharmacist may Dispense a refill of a Prescription Drug, not to exceed a thirty (30) day supply, without Practitioner authorization if:

(1) in the Pharmacist’s professional judgment, the Prescription Drug is essential to the maintenance of the patient’s life or to the continuation of therapy;

(2) the Pharmacist makes a good faith effort to reduce the information to a form that may be maintained for the time required by law or rule, indicates it is an “Emergency Refill Prescription,” and maintains the record as required by state and federal law, as well as state and federal disaster agencies for consideration for possible reimbursement programs implemented to ensure continued provision of care during a disaster or emergency; and

(3) the Pharmacist informs the Patient or the Patient’s agent at the time of Dispensing that the Prescription Drug is being provided without the Presciber’s authorization and that authorization of the Practitioner is required for future refills.

(B) For the duration of the State of Emergency, in an effort to provide patients with the best possible care in light of limited Drug availability and/or limited information on patients’ current Drug therapy, a Pharmacist may initiate or

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modify Drug therapy and Dispense an amount of such Drug to accommodate a patient’s health care needs until that patient may be seen by a Practitioner. Pharmacists performing such activities must utilize currently accepted standards of care when initiating or modifying Drug therapy. These activities may be undertaken if:

(1) in the Pharmacist’s professional judgment, the Prescription Drug is essential to the maintenance of the Patient’s life or to the continuation of therapy;

(2) the Pharmacist makes a good faith effort to reduce the information to a form that may be maintained for the time required by law or rule, indicates that Drug therapy has been initiated or modified due to a disaster or emergency, and maintains the record as required by state and federal law; and

(3) the Pharmacist informs the Patient or the Patient’s agent at the time of Dispensing that the Prescription Drug is being provided without the Practitioner’s authorization and that authorization of the Practitioner is required for future refills.

(C) The Practitioner and Pharmacist shall not incur any liability as a result of the performance of these activities in good faith pursuant to this section.

Section 5. Temporary Recognition of Non-Resident Licensure (A) When a State of Emergency is declared due to a Public Health Emergency:

(1) a Pharmacist not licensed in this State, but currently licensed in another state, may Dispense Prescription Drugs in areas affected by the Declared Disaster during the time that the State of Emergency exists if:

(a) the Board can verify current licensure in good standing of the Pharmacist directly with the state or indirectly via a third-party verification system; and

(b) the Pharmacist is engaged in a legitimate relief effort. (2) a Certified Pharmacy Technician, Pharmacy Technician, or Pharmacy Intern

not registered or licensed in this State, but currently registered or licensed in another state, may assist the Pharmacist in Dispensing Prescription Drugs in affected Disaster Areas during the time that the State of Emergency exists if:

(a) the Board can verify current registration or licensure in good standing of the Certified Pharmacy Technician, Pharmacy Technician, or Pharmacy Intern directly with the state or indirectly via a third-party verification system; and

(b) the Certified Pharmacy Technician, Pharmacy Technician, or Pharmacy Intern is engaged in a legitimate relief effort.

(3) a Wholesale Drug Distributor not licensed in this State, but currently licensed in another state, may Distribute Prescription Drugs in affected Disaster Areas during the time that the State of Emergency exists if:

(a) the Board can verify current licensure in good standing of the Wholesale Drug Distributor directly with the state or indirectly via a third-party verification system; and

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(b) the Wholesale Drug Distributor is engaged in a legitimate relief effort. (4) the temporary recognition of non-resident licensure or registration shall cease

with the termination of the State of Emergency.

Section 6. Temporary Pharmacy Facilities or Mobile Pharmacies (A) Pharmacies located in Declared Disaster Areas, non-resident Pharmacies, and

Pharmacies licensed in another state but not licensed in this State, if necessary to provide Pharmacy services during a State of Emergency, may arrange to temporarily locate or relocate to a Temporary Pharmacy Facility or Mobile Pharmacy if the Temporary Pharmacy Facility or Mobile Pharmacy:

(1) is under the control and management of the Pharmacist-in Charge or designated supervising Pharmacist;

(2) is located within the Declared Disaster Area or affected areas; (3) notifies the Board of its location; (4) is properly secured to prevent theft and diversion of Drugs; (5) maintains records in accordance with laws and regulations of the state in

which the disaster occurred; and (6) ceases the provision of services with the termination of the State of

Emergency, unless it is successfully licensed by the Board of Pharmacy in accordance with Article V of this Act.

(B) The Board, in accordance with Board rules, shall have the authority to approve or disapprove Temporary Pharmacy Facilities or Mobile Pharmacies and shall make arrangements for appropriate monitoring and inspection of the Temporary Pharmacy Facilities and Mobile Pharmacies on a case-by-case basis. Approval of Temporary Pharmacy Facilities and Mobile Pharmacies will be based on the need, type, and scope of Public Health Emergency, as well as the ability of the Temporary Pharmacy Facilities or Mobile Pharmacies to comply with state and federal drug law.

(C) A Temporary Pharmacy Facility wishing to permanently operate at its temporary site must be licensed by the Board in accordance with Article V of this Act.

(D) Mobile Pharmacies placed in operation during a State of Emergency may not operate permanently, unless approved by the Board.

Comments …

Section 1. Comment States may consider adding the following, more detailed language, which specifically addresses drug disposal and reporting requirements in the case of an emergency or disaster, to their emergency rules or guidelines: Disposal of Prescription Drugs in Pharmacies Affected by a Certain Disasters 1. For pharmacies that sustain flood and/or fire damage in the Prescription department or

other damage resulting in an irrevocable loss of the Drug inventory, the entire Drug

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inventory, including Drugs awaiting pick up by Patients, becomes unfit for Dispensing. In such a case, an accurate record of Prescription Drug losses should be prepared by the Pharmacy.

2. For Pharmacies that experience a loss of power for an extended period of time, the Drug inventory must be evaluated for continued product integrity using USP standards. For example, medications with labeling requiring storage at “controlled room temperature” must be kept at between 68◦ F and 77◦ F, with brief deviations of between 56◦ F and 86◦F.. Medication inventories found to have been stored outside of USP standards become unfit for Dispensing. In such a case, an accurate record of Prescription Drug losses should be prepared by the Pharmacy. For Pharmacies with questions on USP product integrity standards, contact USP at 800/227-8772.

Reporting of Theft or Loss of Controlled Substances During an Emergency or Disaster 1. In circumstances of theft by looting, burglary, etc., where evidence or witnesses indicate

the medications were taken by someone, the nearest DEA Diversion Field Office must be notified by telephone, facsimile, or brief written message of the circumstances of the theft immediately upon discovery. In addition, the Pharmacy must complete DEA Form 106–Report of Theft or Loss of Controlled Substances, found at www.deadiversion.usdoj.gov, to formally document the actual circumstances of the theft and the quantity of controlled substances involved, once this information has been conclusively determined.

2. In circumstances of damage or where Drugs were irrevocably lost to flooding or other circumstance, such information must be reported on DEA Form 41 – Registrants Inventory of Drugs Surrendered, found at www.deadiversion.usdoj.gov.

3. The amount stolen or lost may need to be calculated by taking the most recent controlled substances inventory, adding the amount purchased since that date, then subtracting the amount Dispensed and Distributed since that date. In the absence of a calculated amount, a best estimate should be reported.

Disposal of Prescription Drugs Irrevocably Lost in an Emergency or Disaster 1. Controlled Substances. Reverse Distributors, either individually or in concert with other contractors, are

equipped to dispose of controlled substances. Contact your primary Distributor for their recommendations for a reverse Distributor or contact a reverse Distributor directly.

2. Contaminated Medical Debris Non-controlled substance Prescription Drugs and Devices contaminated with flood water

or other contaminants should be disposed of using a medical waste transportation, processing, and disposal system vendor. Such vendors must be licensed by the state.

3. Hazardous Debris Materials are deemed hazardous if they are ignitable, corrosive, toxic, or reactive.

Prescription Drugs considered hazardous include, but are not limited to, epinephrine, nicotine, nitroglycerin, physostigmine, reserpine, selenium sulfide, chloral hydrate, and many chemotherapy agents, such as cyclophosphamide, chlorambucil, and daunomycin. Other hazardous items that might be found in a Pharmacy include paints, varnishes and thinners, alcohol, batteries, mercury thermometers, and blood pressure cuffs. It is recommended that Pharmacies handle all contaminated Prescription medications as

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hazardous debris and dispose of it using a hazardous waste collection and disposal company. These companies must be licensed by the state.

4. Commercial Waste Over-the-counter Drugs and other store shelf material may be disposed of in the

commercial waste stream.

Section 2(B). Comment Boards may consider identifying the official who has authority to issue an “Emergency Prescription Drug Order” and reviewing this on a regular basis.

Section 3(A)(1). Comment Although these services are important, in times of a disaster or emergency, it may not be possible to perform a Prospective Drug Review or provide counseling on Dispensed Drugs.

Section 4(A). Comment Boards may consider contacting the US Drug Enforcement Administration ahead of time to ensure these provisions are applicable to controlled substances.

Section 4(B)(2). Comment Boards should be cognizant that state and federal disaster agencies, to ensure continued provision of care during disasters or emergencies, have programs that consider reimbursement requests for medication providers and may request Board assistance in the dispersal of funds. Records of dispensing will likely be needed for possible reimbursement consideration. In addition, records may also be used for post-event evaluation of care.

Section 5(A)(1)(a). Comment

If the information cannot be verified directly by the Board of Pharmacy in which the Non-Resident Pharmacist is licensed, NABP’s Clearinghouse may be utilized to verify that a Non-Resident Pharmacist has not had disciplinary action taken against his or her license.

Section 6(A). Comment Boards may consider contacting the US Drug Enforcement Administration ahead of time to ensure that controlled substances may be delivered to and Dispensed from temporary or mobile Pharmacy facilities.

Section 6(a)(3). Comment Boards may choose to require “approval” of a Temporary Pharmacy Facility or a Mobile Pharmacy, as opposed to requiring only “notification.” “Notification” may imply that the Board of Pharmacy has approved the location of the Temporary Pharmacy Facility or Mobile Pharmacy.

Section 6(d). Comment Although many states do not allow the permanent or temporary licensure of Mobile Pharmacies, states that do allow the licensure of Mobile Pharmacies may consider implementing special requirements for permanent licensure; for example, a state may limit Mobile Pharmacies to operation only by nonprofit organizations and only in communities that are medically underserved.

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Appendix C: Emergency and Disaster Resources Provided by NABP

NABP Clearinghouse/Expedited Licensure Transfer Services The NABP Clearinghouse serves as a national database of educational, competence, licensure, and disciplinary information on pharmacists licensed by the boards of pharmacy. On a daily basis, the Clearinghouse provides boards with the information necessary to determine the acceptability and qualifications of candidates requesting the transfer of examination scores and licenses into their jurisdictions. In an emergency or disaster scenario, the Clearinghouse can be used to quickly verify licensure in good standing for boards that must quickly issue temporary licenses to licensure transfer applicants. In addition, these verification requests can be expedited, with information provided to boards verbally, via e-mail, in written format or in any form requested by the board. Pharmacists and other licensees who are deemed clear of disciplinary sanctions and/or whose licenses have been verified, can also be listed on the NABP Web site.

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References

1. US Department of Homeland Security. National Response Plan. December 2004. Available at www.dhs.gov/interweb/assetlibrary/NRP_FullText.pdf Accessed October 2, 2006.

2. US Public Health Service Commissioned Corps. The Mission of the Commissioned Corps. Available at www.usphs.gov/html/mission.html Accessed October 2, 2006.

3. Centers for Disease Control and Prevention. Emergency Preparedness and Response, Strategic National Stockpile. Available at www.bt.cdc.gov/stockpile/ Accessed September 30, 2006.

4. Georgia Pharmacy Foundation. An Action Plan for State Pharmacy Associations to Respond to Natural or Man-Made Disasters. March 1996.

5. US Department of Homeland Security. Ready Business Mentoring Guide: Working with Small Business to Prepare for Emergencies. Available at www.ready.gov/business/_downloads/mentor_guide.pdf Accessed October 2, 2006.

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